Night Float

Major highlights from the previous night:

19:05  RMT call from a village health aide regarding a 37-yr-old female who had been drinking, then blacked out and had an unwitnessed fall onto an unknown object that left a puncture wound at the crown of her head.  During the day, we would have just put the patient on a commercial flight to Bethel for further evaluation in the ER and a possible head CT, but at night the major mode of transportation is medevac which should only be activated when critical care is necessary.  Pt was as lucid as one can be while intoxicated, no alarming neurologic deficits, but the health aide called to report that the puncture wound was actively bleeding.  The photos she sent over telemed were a bit blurry and did not give any sense of the depth of the wound.  How to manage this by telephone?  I told her to put several layers of gauze on the wound, then wrap it as tightly as humanly possible with an ace bandage, then apply ice to the region of the wound.  20 minutes later she called to report that the bleeding had stopped and the patient was sobering up.  Disaster averted.

20:53  I admit a 16-yr-old boy with suicidal ideation whose parents were involved in a tragic murder-suicide just a few months ago; he was the one who discovered their bodies and had to break the news to his younger sisters.  Suicide has become such an alarmingly common problem in the Yukon-Kuskokwim Delta that several of the Iditarod competitors this year dedicated their race to suicide prevention.

21:30  A 16-yr-old primip in OB who had just given birth several hours ago after a 3-day induction for mild preeclampsia starts bleeding.  We give her 1000 mcg of misoprostol and the bleeding ceases.  Her post-delivery CBC shows a drop in hematocrit from 34 to 23.4.

22:44  I pick up several ER patients, one of which is a 13-month-old girl with a nasty-looking abscess on her R posterior thigh with a large area of surrounding cellulitis.  Her mother seems unconcerned about the infection, and I am worried about mother's ability to administer daily medication and manage dressing changes, so I decide to hospitalize the girl and start her on IV antibiotics.  After perusing her old chart, I discover that she has been hospitalized twice in the past 8 months for large MRSA abscesses with cellulitis,  and that her mother has been investigated by the Office of Children's Services for suspected neglect.

00:13  The OB nurse pages me because the 16-yr-old primip produced another large gush of bright red blood. I medicate her with fentanyl & versed, then manually extract a large 200 cc blood clot from her uterus and order an additional CBC for morning.

02:22  More RMT calls about infants in respiratory distress, both of whom end up getting medevac'd.

03:10  More ER patients, mostly with viral respiratory infections that are stable for discharge.  The ones who don't have family or friends in Bethel can stay in the hospital-owned hostel overnight and return in the afternoon for a recheck before flying home to their villages.

04:31  Several RMT calls about minor injuries from fisticuffs.  The health aides aren't trained to do laceration repair, so they mainly irrigate the wounds and apply butterfly bandages to hold the wound edges together.

06:17  A 21-yr-old primip is admitted to L&D in active labor and quickly progresses to complete dilation.  Instead of the usual stoic tolerance of labor, this primip yells, "That f*ing hurts!" every 10 seconds while pushing her baby out.  Thankfully, it only takes 4 pushes to deliver her vigorous baby boy.